Projected Health Outcomes Associated With 3 US Supreme Court Decisions in 2022 on COVID-19 Workplace Protections, Handgun-Carry Restrictions, and Abortion Rights

Key Points Question What are the probable health consequences of 3 US Supreme Court decisions in 2022 that invalidated COVID-19 workplace protections, voided state laws on handgun-carry restrictions, and revoked the constitutional right to abortion? Findings In this decision analytical modeling study, the model projected that the Supreme Court ruling to invalidate COVID-19 workplace protections was associated with 1402 deaths in early 2022. The model also projected that the court’s decision to end handgun-carry restrictions will result in 152 additional firearm-related deaths annually, and that its decision to revoke the constitutional right to abortion will result in 6 to 15 deaths and hundreds of cases of peripartum morbidity each year. Meaning These findings suggest that over a decade, the 3 Supreme Court decisions examined here will contribute to the loss of nearly 3000 US lives and possibly many more.


eMethods. Supreme Court Rulings Examined in This Study and Approach to Modeling
National Federation of Independent Business v. OSHA

I. Background and Timeline
OSHA issued a Vaccination and Testing Emergency Temporary Standard (ETS) on November 5, 2021. 1 The ETS applied to entities (businesses, non-profits entities, and some governmental agencies) employing 100 workers or more, excluding employees who worked (1) only outdoors; (2) only at home; (3) or in places where no other individuals were present. 1 It required covered employers to "develop, implement, and enforce a mandatory COVID-19 vaccination policy, with an exception for employers that instead adopt a policy requiring employees to either get vaccinated or to elect to undergo regular COVID-19 testing and wear a face covering at work in lieu of vaccination." 1 The effective date was set at January 4, 2022, with a requirement that unvaccinated workers begin masking on December 5. 2 Immediately after issuance of the ETS, a coalition of states, businesses and other groups filed a petition with the Fifth Circuit US Court of Appeals contending that the rule was unconstitutional, and on November 6 a panel of judges issued a temporary injunction barring enforcement of the rule. 2 The Biden Administration defended the standard in a filing before the court the following Monday, 3 calling for a withdrawal of the court's initial ruling, but on November 12 the Fifth Circuit issued a ruling extending the stay on implementation of the ETS. 4 Meanwhile, other lawsuits had been filed in courts across the country, and 34 of them were consolidated into a single case and randomly assigned to the Sixth Circuit federal appeals court in Cincinnati. 5 On December 17, the Sixth Circuit overturned the Fifth Circuit's decision, effectively reinstating the ETS. 6 The case was immediately appealed, however, to the Supreme Court, and on December 22, the Supreme Court announced that it would decide the case as part of its "shadow docket." On January 7, it decided that OSHA had overstepped its legal authority and voided the ETS.

II. Number of workers who would have been vaccinated under the ETS
We estimated deaths stemming from the Supreme Court's voiding of the ETS by building off of OSHA's 2021 published estimates of the number of people who would have been vaccinated had the ETS remained in force. 7 OSHA also projected health impacts of the ETS for the period April -August 2021, including deaths averted. 7 Our analysis differs from OSHA's in using the actual number of COVID-19 deaths and vaccination rates that occurred in the wake of the January 7, 2022 ruling, whereas OSHA's projections were based on previous months deaths. We also adjusted OSHA's methods to account for delays in implementation of the rule attributable to the lower court decisions.
The starting point for our analysis is OSHA's estimate that 18.9 million workers would have been vaccinated because of the ETS. OSHA used multiple sources to calculate the number of workers who would fall within the parameters of the ETS, excluding, for instance, those expected to exclusively telework. 1

Modelling deaths
We based our estimates of the number of deaths potentially avertable by implementation of the ETS by analyzing two data sources on COVID-19-related deaths.
We first analyzed week-level data on death counts by vaccination status provided by the CDC.
These data reflect deaths that occurred through May 28, 2022 and were obtained on August 8, 2022. 9 In these data, vaccinated cases (as opposed to unvaccinated cases) are those among persons who tested positive for COVID-19 via a SARS-CoV-2 RNA or antigen test that was performed 14 days or more after "verifiably completing the primary series of an FDA-authorized or approved COVID-19 vaccine." COVID-19 deaths are those that occur "in a person with a documented COVID-19 diagnosis who died"; death dates reflect when the individual tested positive for COVID-19 as opposed to the day of death. These data was collected from 31 health departments that collectively represent 71% of the total US population (at the time of data download); data on death were provided by all but one of these departments. We calculated weekly deaths among unvaccinated individuals in three age groups: 18-29, 30-49, and 50-64 age groups. We then calculated the agegroup and week specific proportion of unvaccinated COVID deaths over total COVID deaths.
However, this data, as mentioned, was not nationally-representative. To estimate the total number of deaths among the unvaccinated ages 18-64, we then analyzed week-level death certificate-based data from the National Center for Health Statistics (NCHS) on COVID-19 related deaths (ICD-10 code U07.1), 10 and applied the CDC-data derived age-group and week-specific ratio of unvaccinated / total COVID deaths to the corresponding age-group and week-specific NCHS COVID death figures. the direct and narrow impact of the expanded issuance of carry permits in those specific jurisdictions only, erring towards conservative estimates.

II. Policy impacts for affected states
The immediate impacts for firearm policy in affected states will still likely be substantial. As Donahue further argues: "The narrow effect of the decision will be to expand gun carrying outside the home in the relatively limited number of states that have tried to be more restrictive in this dimension … In turning these states into "rightto-carry" states that essentially give anyone (other than a narrow class of prohibited possessors) the right to carry handguns outside the home, the Court determined that its judgment about gun policy trumped the legislative determinations based on strong empirical evidence that promiscuous gun carrying will elevate violent crime." 19 However, by most accounts, the impact of this ruling will still be shaped by state policy responses.
While the Supreme Court declared subjective "may issue" criteria to be unconstitutional, it left room for states to continue to impose (and potentially expand) objective criteria for the issuance of carry permits. Appendix Table 2 reviews the diverse and conflicting steps taken by state governments in the immediate wake of the Bruen decision.
State policy, in other words, could substantively modify the impact of Bruen, although a key (and unanswered) question is which of these policies will withstand further legal challenges. For instance, in response Bruen, New York State passed legislation that created numerous new restrictions on handgun carry; however, in October, a Federal court declared many of these provisions unconstitutional. 20 Hence, we modelled three different "state policy scenarios" for how the court's decision could affect these jurisdictions.
In the first policy scenario, we assume that the impact of Bruen in each jurisdiction will be entirely offset by policies that fully constrain a growth in handgun carry, and that these policies furthermore survive legal challenge. We view this as an unlikely outcome, but provide it as our "lower bound" estimate.
In the second scenario, we assume that Bruen instigates statutory change that cannot be offset by other legislation or state policy change (possibly because such policies do not withstand legal challenge). Consequently, in this scenario, each state experiences the full "expected outcome" of right-to-carry (RTC) laws based on the experiences of other states that have implemented such policies in the past. We use this scenario to model our "upper bound" estimate, although it may nevertheless be conservative for two reasons. First, as previously noted, a broader legal shift due to Bruen could have larger -although difficult to project -effects nationwide. Second, we did not model potential spillover effects on neighboring states from policy changes in the 7 affected jurisdictions; however, a growing body of research points to such spillovers (e.g. via gun theft) as an important mechanism connecting RTC laws and violent crime. 21 Finally, for our primary policy scenario, we assume that state policy responses will partially offset the impact of Bruen on handgun carry. In this scenario, we assume half the "expected outcome" of the implementation of RCT laws in each state.

III.
Modelling "right to carry" on health ("expected outcomes") Next, we derived estimates of the "expected outcome" of the implementation of a "shall issue" or RTC legal standard via a review of the literature. Our focus was on more recent (and methodologically stronger) studies. As noted by Donahue et al., 21 while older studies of the effects of RTC laws had mostly null findings, "the predominant conclusion from studies in the last five years has been that RTC laws increase violent crime." In part that may be because the impact of RTC laws has changed over time; as we are interested in the contemporary (i.e. not historical) effect of these laws, we rely on analyses that use more recent data. However, perhaps more importantly, and as others have noted, 21,22 much of the older literature had serious methodological shortcomings.
Key recent national studies from the past 5 years are summarized in Appendix Table 3.
Each of the studies summarized in Appendix Table 3 demonstrates positive associations between RTC laws and firearm deaths and/or violent crime, although not all associations with deaths are significant. Effect estimates for impacts on firearm homicide or overall homicide range from a 3% increase (Schell et al. 22 ) to a 9% increase (Siegel et al.). 23 Donhue et al. 21 , in a city-based analysis, also identified a 9% increase but standard errors were wide and the estimate was not statistically significant (although violent crime estimates were larger and significant). Crifasi et al. 24 identified a 14% reduction in death with the introduction of permit-to-purchase laws (implying a 16% increase in deaths with their nullification), but these laws are related yet not directly comparable to RTC laws and so we did not use this estimate.
Based on this range of effect estimates, we assumed a lower-bound "expected outcome" estimate of a 3% increase in firearm-related deaths in affected states. For our higher-bound estimate, we assumed a 9% increase. For our mid "expected outcome" estimate, we used the midpoint between these two estimates, or 6%.

IV. Estimated additional firearm deaths
We estimated the impact of Bruen on firearm deaths by applying each of the 6 unique relative changes in firearm-related mortality to 2020 firearm-related homcide to each of the 6 affected states as well as the District of Colombia, using data on all abstracted from CDC WONDER Underlying Cause of Death data. 25 Although we present all 6 mortality estimates in the appendix (Appendix Table 5), in the manuscript (Table 2) we only present our "low" estimate (0% effect on gun deaths), our middle or primary estimate (a 4.5% increase), and our high estimate (a 9% increase using the highest estimate for each parameter). Each such estimate, however, for reasons reviewed above, should be interpreted as conservative.

V. Estimated additional firearm injuries
To estimate the number of additional firearm-related injuries as a result of Bruen, we relied on a recent national study by Kaufman et al. 26 Table 6).
Dobbs v. Jackson Women's Health Organization

Modelling foregone abortions
We first projected the number of foregone abortions by state because of the overturning of Roe v.
Wade. To do so, we used the approach of Myers et al, 27 which we updated for this paper.
In brief, in their previous study, Myers et al. 27  2023 as having abortion bans, per the Myers database. 29 In the second scenario, we projected the impact if states that the Guttmacher Institute considers "likely" to enact abortion bans. 31

Deaths from Foregone Abortions
To examine the effect of foregone abortions on maternal mortality, we followed a similar approach as Stevenson et al., who projected additional deaths caused by a total national abortion ban. 32 We first calculated the state-level maternal mortality rate in 2018-2020 using death-certificate data on state-level maternal mortality for 2018-2020 from the National Center of Health Statistics 33 and data on 2018-2020 births from CDC WONDER. 34 We also estimated the number of maternal deaths by state in 2019 by applying these state-level 2018-2020 rates to the number of births in each state in 2019, also obtained from CDC WONDER. 34 We drew on these estimates of 2019 state-level maternal mortality rates, as well as the number of abortions performed in each state in 2020 according to a Guttmacher analysis, 35 to calculate the number of maternal deaths from foregone abortions by applying the method of Stevenson. 32 Stevenson assumed that each foregone abortion results in 0.8 additional births (the figure is less than 1 as some pregnancies end in miscarriage), and then multiplied 0.8 * number of abortions denied * pregnancy-related mortality rate per birth. Stevenson subtracted from this figure an estimate of the number of pregnancy-related deaths among patients who obtain abortions (0.7 / 100,000) to estimate additional net deaths due to foregone abortions. Stevenson projected smaller effects for the first year of ban; we chose to model deaths in the first full year following the implementation of a ban, but otherwise used her approach, albeit applying it to our state-level, travel-time based estimates of foregone abortions, described above.

Postpartum Hemorrhage due to Foregone Abortions
As an indicator of increased morbidity stemming from foregone abortions among those with unwanted pregnancies, we calculated the number of additional cases of postpartum hemorrhage annually. To do so, we relied on a study by Reale et al., who examined trends in postpartum hemorrhage using the National Inpatient Sample, a large all-payer hospital administrative database. 36 Reale et al. estimated a 3.21% postpartum hemorrhage rate among all deliveries in 2014. 36 We applied this rate to the number of foregone abortions (minus 20% to account for miscarriage, following Stevenson 32 ) annually.

Membranes (PPROM)
Multiple media reports have described harmful alterations in obstetrical care due to abortion bans, including for treatment of ectopic pregnancy, previable premature rupture of membranes (PPROM), and eclampsia. [37][38][39] This has been attributed to the "chilling effect" of these laws, i.e. physicians' or hospitals' concerns about facing criminal charges from provision of abortion care even when the pregnant patient's life is in danger (which, in most states, theoretically qualifies as an exemption from state abortion bans). Although there is some uncertainty as to how this will impact the care of patients with such conditions in the longer term, we modelled the impact of Dobbs for treatment of one condition -previable PPROM (or PPROM at the limits of fetal viability) -where a recent study found evidence of harm from an abortion ban. 40 That study examined the effect of Texas law SB 8, a 6 week abortion ban, on the management of previable PPROM. 40  California Guidance from the state attorney general noted that firearm licensing authorities and law enforcement could not continue to require "good cause" prior to issuance of a carry permit, although requirements to show "good moral character" could continue to be enforced. 43 New laws passed in the wake of the decision increased potential legal culpability of firearms manufacturers, further restricted firearms advertising to young people, and added more restrictions to "ghost guns," although these are expected to undergo court challenge. 44 Hawaii The attorney general instructed law enforcement to grant concealed carry licenses without requiring that applicants are an "exceptional case." 45

Maryland
The governor responded to the decision by removing restrictions on access to concealed carry permits. 46  However, Democratic lawmakers are pushing forward a bill to expand gun regulation.

Massachusetts
The Massachusetts Attorney General issued guidance instructing licensing authorities to stop enforcing the "good reason" requirement of the state's license-to-carry law, but instructing them to continue enforcement of "suitability" requirements. In response to guidance from the state, police are removing constraints on carry for a restricted licenses in some communities 48 Meanwhile, Democratic lawmakers are trying to pass legislation that would expand firearm regulation while, they say, ensuring compliance with Bruen. 49 New York Passed an aggressive gun control law creating numerous relatively onerous requirements for a carry permit, including provision of social media accounts, 16-hours of in-person training, re-certification every 3 years, expansion of "sensitive places" where guns are excluded, banning concealed carry in private residents without explicit permission from the owner, and several other restrictions. 50 However, it was widely assumed that these provisions would face court challenge, 50 and indeed in early October a federal court declared some but not all of the provisions unconstitutional. 20 New Jersey In the wake of the ruling and the mass shooting in Uvalde, TX, the governor of New Jersey signed 7 bills into law, including laws to: require firearm training to purchase guns; ban future sale of 0.50 caliber rifles; eventually require sale of micro-stamped firearms; require reporting of ammunition; sales heighten potential penalties for production of ghost guns; and several other measures. 51 Meanwhile, other state gun laws were facing legal challenges. 52  In this recent analysis, Donahue and colleagues again use panel data from 1979 to 2019 to examine the mechanisms by which "right to carry" (RTC) laws lead to more violent crime, looking at gun loss/theft and police effectiveness. They use data from the FBI Uniform Crime Reporting and Supplementary Homicide Reports, and perform a city-level panel data analysis. They first look at impacts on crime, and find that crime rises by 11-15% with introduction of RTC, with significant increase in firearm-related violent crime, firearm-related robbery, and firearm-related aggravated assault. There is a 13% increase in firearm-related homicide offset by a 3.43% fall in nonfirearm-related homicide (an overall 8.5% increase), but none of those estimates are significant. They then proceed to look at potential mechanisms for such effects. They find that crime clearance rates fall by 7.5-15% as a result of RTC laws, which is not explainable by the increase in crime itself. Next, they find that RTC laws are associated with a 35% increase in the dollar value of stolen guns per capita. This suggests that the number of stolen guns would increase by about 100,000 (in 2015) as a consequence of RTC laws, which is similar to a survey based estimate from their earlier work. They argue that previous studies failed to account for these sorts of unintended consequences of RTC laws.
Provides robust evidence, similar to Donohue 2019, of association between RTC laws and violent crime. There is a 8.5% overall increase in homicide, but the effect estimate is not statistically significant.

Doucette et al. 54
This analysis employed a quasi-experimental design examining the association between adoption of "shallissue" laws and state-level violent crime, with national data from 1980-2019. Demonstrated that the implementation of shall-issue laws was associated with a 9.5% increase in gun assaults, as well as an 8.8% increase in non-gun homicides; the increase in gun homicides did not reach statistical significance. Effects appeared larger in states without violent misdemeanor prohibition provisions.
Provides further evidence of effect of "shall issue" laws and firearm assaults, finding a 10% increase. Schell et al., 2020 22 Schell et al. begin by noting that various studies have yielded varying results and conclusions, even when using the same data, suggesting that some methods may not have been appropriate. Proceeded with a simulation to examine how different methodologies compare in terms Provides evidence for impacts of RTC on firearmrelated deaths, with a 3% estimated effect relative to a more restrictive baseline. of modelling the impact of state laws on gun access/use and outcomes, and then used their "more appropriate statistical approach" to look at association of child access prevention (CAP), RTC, and stand your ground (SYG) laws on firearm deaths. Data was from 50 states for 1980-2016, with state-level firearm death data from the Vital Statistics System (VSS). The looked at 6 years after implementation, and used a Bayesian methodology. They find that CAP are associated with a 6% decline in firearm deaths, RTC with a 3 % increase, and SYG with a 3% increase. Together, taking a more restrictive approach on these 3 gun regulation issues could reduce firearm deaths by 11%.

Donahue et al, 2019 55
This analysis used two different methodologies to examine the impact of RTC laws in the US.
First, using panel data, the analysts conducted a simple difference-in-differences analyses, and found that from 1977 to 2014 there was a 42.3% drop in violent crime in states that never adopted RTC laws, versus a 4.3% drop among states that adopted such laws between 1977 and 2014 and a 9.9% drop among states that had adopted them before 1977. They then performed a panel data analysis for the full 1977-2014 period using two different models. Their own preferred models includes various demographic variables as well as variables for police and incarceration. This model finds a significant effect of RTC laws on increasing the violence crime rate (9.0%) and property crime rate (6.5%). There are nonsignificant and very imprecise effects for murder rate (2.27%) and firearm murder rate (2.90%). Note that one serious limitation of this study design is that it fails to account for spillover from RTC states to non-RTC states (i.e. in gun trafficking). They then proceed to repeat the analysis using the 36 co-variates employed in the study of Lott and Mustard (LM), which they argue is flawed and introduces statistical noise. They also show that the LM specification, but not their own, respects the parallel trends assumption. Moreover, when examining states that implemented RTC laws in the period 2000-2014 (following the end of the crackcocaine epidemic), they found that both their model and the LM model show an increase in murder (and firearm murder) due to RTC laws (Appendix C).
Provides robust evidence for RTC restrictions on violent crime. Impacts on homicide are less precise, and mostly not significant overall, although do emerge more clearly in the post-2000 panel data analysis.
Strengths: Robust causal inference methodology; recent data through 2014.
Next, they examine the impact of RTC laws using a "synthetic controls" approach. Using this approach, they find that 31 states which adopted RTC laws experienced a mean effect after 10 years of a 14.3 percent increase in violent crime. The effect on murder is less precise and not significantly significant in the synthetic controls model. They find that the synthetic controls approach shows an estimated increase in murder of 8.7% (p<0.1) and in firearm murder of 15.3%. Siegel et al., 2019 23 This analysis used the State Firearm Law Database, compiled by the authors, which provides state-year level data on state firearm laws. It used CDC Wonder for gun-related mortality at the state and annual level . It examined 10 state laws, including "shall issue" laws, and lagged the effects by one year. They used a DiD approach, as well as both state and year fixed effects, while controlling for 12 other state-level factors. When examined individually, universal background checks, violent misdemeanor laws, and "shall issue" laws were associated with higher homicide. However, controlling for all 10 laws at the same time demonstrated an association between universal background checks and 14.9% lower overall homicide; an 18.1% lower homicide with violent misdemeanor law; and 9.0% higher homicide rates with "shall issue" rules. Seven other types of laws were not independently associated with homicide. In a falsification test, each of these laws were associated with firearm homicide but not non-firearm homicide. For suicide, four of 10 laws were separately associated with suicide but only bans on junk guns and permit-less carry were associated with suicide, and both laws failed the falsification test.
Provides evidence for adverse effect of "shall issue" laws on homicide but not suicide; point estimate: 9.0% higher homicide.

Crifasi et al., 2018 24
The authors performed interrupted time series analysis examining effect of gun laws on homicide, from 1984-2015 in urban counties. They used CDC WONDER data for gun homicide, and included several state-level controls. They researched state laws and created month/day/year specific indicator variables for implementation of policies and found an association between permit-to-purchase (PTP) laws and a 14% reduction in firearm homicides; comprehensive background check-only laws and a 16% increase in firearm homicides; RTC and a 4% increase in firearm homicides; SYG and a 7% increase in firearm Provides evidence for beneficial effect of "permitto-purchase" laws on homicide. Did not examine suicide.
Point estimate: 14% lower homicide with permit-topurchase homicide. 4% higher with right to carry laws.
homicides; violent misdemeanor prohibitions and a 14% increase in firearm homicides. None of the laws had an impact on non-firearm homicide. They suggest that their estimates for the effect of laws excluding those with violent misdemeanors from gun purchases may be biased.
Limitations: Inconsistent results (with harm apparent with some laws) suggesting potential bias in design. Siegel et al., 2017 56 These researchers used CDC WISQARS database for age-adjusted homicide rates overall (1991-2015) and FBI Uniform Crime Reports data for handgun vs. long-gun homicide. They constructed a state law database to look at effect of "shall issue" provisions, controlling for 12 state-level factors associated homicide, as well as other state firearm laws apart from "may issue" vs. "shall issue." They found that "shall issue" concealed-carry laws were associated with 6.5% higher homicide vs. "may issue" states. This effect held for firearm homicide rates (but not non-firearm suicide), and for handgun homicide (but not long-gun homicide) and was robust to various other specifications.
Provides evidence for adverse effect of "shall issue" laws on homicide. Did not examine suicide. 3% 6% 9% Note: Each cell represents a potential relative increase in firearm-related mortality due to Bruen, and is the product of the assumed state policy response (0-100%, seen in the row labels) and the "expected outcome" from RTC legislation estimates (3-9%, seen in the column headers).